Texas Department of Number: PGP 01.07 Criminal Justice January 3, Date: 2011 TCOOMMI Page: I of 5 Program Guidelines and Procedures Supersedes: January 6, for Adult Transitional Case Management 2009 Subject: Purpose: Case Management process for adult offenders on criminal justice supervision who do not require intensive case management services. To provide a process to TCOOMMI contract programs for identified offenders who may be considered for, or are receiving, Transitional Case Management services. Contents: Section I Referral Section II Admission Criteria Section III Benefits Assistance Section IV Interdisciplinary Team (IDT) Section V Treatment/Service Plans Section VI Case Manager Services Section VII Transition Planning Section VIII Discharge Procedures: I. Referral A. At least monthly, the TCOOMMI Program Director and/or designee shall meet with a representative of the Community Supervision and Corrections Department (CSCD) to review possible referrals to TCOOMMI Case Management. B. In areas where Parole Case Management is funded, at least monthly, the TCOOMMI Program Director and/or designee shall meet with a representative of the Parole Office to review possible referrals to TCOOMMI Case Management. C. When a probationer is determined to be an appropriate referral the CSCD officer will, in counties that have a CJAD funded Initiative Caseload, ensure that the offender is placed on the specialized Mental Health Initiative probation caseload prior to admission to the TCOOMMI program. D. Parole referrals may be on Special Needs Offender Program, Sex Offender, or Super Intensive Supervision Program caseloads. E. If eligible, offenders shall be admitted to the TCOOMMI program within 7 days of referral.
II. Admission Criteria The intent oftcoommi Transitional Case Management is to provide transitional mental health services to offenders with severe and persistent mental illness who have been served on the TCOOMMI Intensive Case Management case load and require ongoing services to reduce risk of recidivism, reduce or stabilize symptoms while linking the offender to natural and or alternative supports. A second intent is to provide initial Case Management services to offenders with a severe and persistent mental illness who present with very little risk of harm and a current level of functioning that does not require intensive levels of care to maintain community tenure. The general focus of services is to reduce or stabilize symptoms, reduce the risk of recidivism, improve the level of functioning and prevent deterioration of the offenders condition, liaison with the community supervision or parole regarding integrated chronic care needs, increase awareness of and participation with community and natural supports, increase skills in self advocacy and increase ability to participate in independent mental health care. The service focus is on maintaining baseline level of functioning, decreasing risk of recidivism, increased use of core community reintegration skills, increase in self reliance, increased independent living skills, and effective peer, community, and family interactions. Therefore: A. All offenders admitted to TCOOMMI Case Management shall score a 2 or higher on at least 5 of the 9 functional dimensions of the Texas Recommended Assessment Guidelines for Adults (excluding Response to Medication Treatment). B. At least 90% of the TCOOMMI Case Management easeload shall be felony offenders. C. An offender with Veteran's Benefits shall not be excluded from TCOOMMI services based solely upon that benefit status. D. Review of the Offender's Risk Needs or Parole Guidelines Score shall be used to assist in determining level of care. This review shall be documented in the offender's clinical record. E. Services for TCOOMMI Intensive and Transitional Case Management are authorized for a period not to exceed two years. Authorization for services in excess of two years must be obtained by TCOOMMI. (See Attachment) III. Benefits Assistance A. Within five (5) days of the offender's admission into the program, the Case Manager (CM) shall: I. Ensure that the offender is screened for possible eligibility for local, state, and federal benefits (food stamps, Supplemental Security Income, Medicaid, Medicare, etc.) 2. Ensure that applications have been initiated for applicable benefits. B. Within five (5) days of the prescription for psychotropic medications, the CM shall ensure that appropriate Prescription Assistance Program (PAP) application is submitted. C. Ensure these services are documented within the clinical record. 2
IV. Interdisciplinary Team (IDT) A. An IDT shall be comprised of at least the following individuals: 1. the offender, 2. the offender's supervising officer, 3. the CM, 4. the Program Director and/or designee, and the 5. psychiatrist, and/or nurse when medical staff is available. B. The IDT shall: 1. Provide input on and develop the initial Treatment/Service Plan within thirty (30) days of the offender's admission. 2. Review and/or modify the Treatment/Service Plan every ninety (90) days, or more frequently as indicated by the offender's need. V. Treatment/Service Plan A. Treatment/Service Plans shall: 1. Be developed based upon all areas of the offender's needs. 2. Be individualized for the specific offender. 3. Include goals, objectives, and strategies for achieving the goals and objectives. 4. Initially be developed within thirty (30) days of the offender's admission into the program with input from the IDT. 5. Be reviewed and/or modified by the IDT every ninety (90) days, or more frequently as indicated by the offender's need. 6. Include recognition of barriers, interventions, and goals to move into independent (Non-TCOOMMI) mental health care. VI. Case Manager Services A. The CM shall: I. If the Case Manager is solely a Transitional Case Manager: Maintain a caseload of no fewer than 50 and no more than 75 offenders at any one time. 2. Coordinate intake and assessments as needed. 3. Facilitate IDT meetings. 4. Identify and coordinate the offender's access to needed therapeutic and mental health services, including inter- and intra-agency resources. 5. Ensure the provision of skills training and service coordination to include: a. Minimum of 1.5 face to face contact hours per month. 1. Hours can be provided by and met in combination with CM, nurse, psychiatrist, benefits specialist, and/or skills trainer. 11. Hours may be individual or include group. b. Services which assist the offender in coordinating access to necessary care and services appropriate to the offender's needs. Activities with 3
interventions targeted at engagement and education on service value. Skills training and education which address the persistent and severe mental illness and symptoms related problems that interfere with the offender's functioning and increase the risk of recidivism and deterioration in level of functioning. Skills training and education which provide the opportunity for the offender to develop skills needed to function as appropriately and independently as possible in the community and facilitates the offender's community reintegration and or increases the offender's community tenure. e. Document offender's progress in developing natural and or alternative supports which facilitate the ability to move out oftcoommi services. d. Document barriers to the offender's progress in moving out of TCOOMMI services and develop interventions to address barriers. 6. Ensure crisis intervention is available twenty-four (24) hours per day, seven (7) days per week. 7. Make at least one(!) collateral contact per month in person or by phone with the offender's supervising officer. 8. Document all activities and contacts in the offender's case file and ensure such documentation meets standards for Medicaid reimbursement. VII. Transition Planning A. Planning for transitioning out of TCOOMMI services should begin at admission. The IDT shall: I. Identify the offender's chronic needs and develop treatment or case management strategies to address barriers. I. Designate an IDT member (usually the CM) to coordinate needed transition services. 2. Determine whether an offender should have gradually reduced TCOOMMI services as a transition to non-tcoommi services. I. Such determination shall be documented 111 the offender's Treatment/Service Plan. II. Approval for service contact hours other than those stated in this procedure shall require approval from TCOOMMI. VIII. Discharge A. The offender should be discharged from the program when he: I. No longer needs TCOOMMI transitional services (or) 2. Completes required community supervision, 3. Has probation or parole revoked 4. Moves outside the MHMR service area. In such case, the MHMR shall follow the Continuity of Care Procedures. 5. Has been arrested and remains incarcerated in a county jail for more than 30 days. In such case, the offender shall be admitted to Continuity of Care and monitored until release or adjudication. 4
l'gl' 01.07 B. If an offender is enrolled in the program for longer than one (I) year, the IDT shall review the case and determine whether the offender should continue in the program. If continuation is decided: I. Request for approval shall be submitted to TCOOMMI. 2. Treatment/Service Plan should include the necessary goals, objectives, and strategies for stabilizing the offender so less intensive services are needed. 5